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erIE:.S <br /> �\j <br /> 5 2015 <br /> c4 ,� MAR 0 SMI JOAQUIN COUNTY <br /> -r � �S4�N�nRONfu9ENTAL HEALTH DEPARTMENT Return this form by the <br /> ENVtFtON�E�cR�s,7 East Hazelton Avenue, Stockton,CA 95205-6232 le of each mor-tth <br /> `�q fay PER 7(��hone:(209)46B-3420 Fax:(209)4fi4-0'138 Web:wvrw.sjgov.orglehd <br /> XTAGE CLEA is REPORT <br /> Company Name: �24—" Report forth m ih of: ar <br /> Company Address: C� S �� Signature: <br /> Street A ressi' p Code <br /> Ali information submitted must be complete, accurate, and legible <br /> GALLONS (R) RESIDUML NAME OF TREATMENT <br /> DATE NAAIE OF BUSkNESS OR ADDRESS WHERE WOR}C WAS DONE (G) GREASETRAP <br /> PUMPED PROPERTY OWNER AUPdPED FACILITY <br /> PLEASE INCLUDE STREET P. DIRECTION. STREET WARE ATJD CITY (C CFIER9CAL <br /> 6 (� G C7 6 l.Z �t�st, <br /> <l ? 06 <br /> ca- <br /> _ Cr, I 31L t l <br /> 6 - �c <br /> `l J � 7Gitv I,GI U o C7C Y- <br /> l� �C--4 <br /> z <br /> ME <br /> Cite a <br /> r� <br /> C <br /> C• <br /> 0-------- <br /> Cqycr <br /> Cil <br /> City <br /> City � <br /> Page of <br /> SEPTAGE CLEANERS REFIORT a <br /> EHD 42.04 <br /> 52127/13 _ <br />